[Effective Use of Combination of Ultrasound-guided Femoral Nerve Block and Lateral Femoral Cutaneous Nerve Block for Harvesting Skin Grafts: Three Case Reports].

The pain of skin graft site after surgery is compara- tively severe. We present three cases of combined of ultrasound-guided femoral nerve block and lateral fem- oral cutaneous nerve block that was effective for har- vesting skin grafts. Case 1 : a 32-year-old man had a split-thickness skin grafting of lateral upper arm harvested from outside of the thigh under general anesthesia, brachial nerve block, femoral nerve block and lateral femoral cutane- ous nerve block. Case 2 : a 39-year-old man had split-thickness skin grafting of lower thigh harvested from outside of the thigh under general anesthesia, femoral nerve block and lateral femoral cutaneous nerve block. Case 3 : a 94-year-old man had split-thickness skin grafting of acrotarsium harvested from outside of the thigh under spinal anesthesia, femoral nerve block, lat- eral femoral cutaneous nerve block and sciatic nerve block. In all cases, there was no pain just after surgery, and postoperative pain was controlled well through the hospitalization with administration of oral analgesic agents.

[A case of transfusion-related acute lung injury following platelet transfusion during the cervical supine surgery].

We report a case of possible transfusion-related acute lung injury (TRALI). The patient is a 69-year-old man who underwent cervical supine surgery Platelet products were transfused pre-and intra-operatively. At the end of the operation, he was fully awake and extubated. Shortly after extubation he showed low oxygen saturation, and we started bag-mask ventilation. A chest X-ray revealed bilateral diffuse pulmonary edema without cardiac enlargement. Thus we inserted endotracheal tube and started positive pressure assist ventilation. Hypoxemia was improved gradually, and he was re-extubated on the fourth day after the operation. The prevalence of TRALI reactions is reported to be high for platelet product and is influenced by patients' underlying clinical condition. Serum anti-leukocyte antibody was negative, but we suspected the possibility of TRALI based on the clinical findings.

[A case of acute exacerbation of interstitial pneumonia after appendectomy managed with spinal anesthesia].

An 88-year-old woman was admitted with acute appendicitis. She had been treated with prednisolone and home oxygen therapy for interstitial pneumonia. Her respiratory state on admission was Grade 2 of Hugh-Jones' classification, and plasma KL-6 and SP-D levels were high. Seven days after the admission, appendectomy was performed under spinal anesthesia. Spinal anesthesia was initiated by injecting 0.5% hyperbaric bupivacaine 2.0ml into L3-4 interspace, and achieved block level was up to T4. During the operation, her respiratory state was stable, but after the operation, dry cough, increase of body temperature, and dyspnea were observed. Chest roentgenogram revealed severe ground glass appearance and reticular shadows bilaterally. Steroid therapy for acute exacerbation of interstitial pneumonia was initiated, but she died on the 13th POD. This case teaches us to take a lot of care in the management of a patient with high plasma level of KL-6 and SP-D.

[Perioperative management of neuroleptic malignant syndrome in a schizophrenic patient scheduled to undergo operation for bowel obstruction].

Neroleptic malignant syndrome (NMS) is a serious side effect of antipsychotic medications. The risk factors for NMS are the patient's physiologic conditions such as dehydration, malnutrition, stress, and additional administration of sedative drugs including haloperidol. We report a case of 62-year-old schizophrenic man with bowel obstruction due to rectal cancer. Colostomy under general anesthesia was scheduled, and he had not taken oral medication. After intravenous injection of haloperidol for sedation, muscle rigidity, high fever, and an elevated serum level of creatine phosphokinase were observed. He was diagnosed as NMS, and sodium dantrolene was administered. After the improvement of NMS, colostomy was done. Dehydration and malnutrition of the patient were severe at the time of operation, and the possibility of NMS developing due to stress was thought to be very high. We administered sodium dantrolene to prevent NMS after the operation, and the management for prevention of NMS is discussed.

[Anesthetic management of the cesarean section in a patient with aplastic anemia].

A 31-year-old woman with aplastic anemia was admitted for the management of delivery at 33 weeks of gestation. Platelet count was 2.3 x 10(4) x microl(-1) on admission. Corticosteroid therapy after admission was not effective, and we decided to manage the delivery with elective cesarean section after platelet transfusion. After forty units of platelet transfusion, platelet count was 8.1 x 10(4) x microl(-1), and we decided to perform cesarean section under spinal anesthesia. Spinal anesthesia was given using a 25-gauge Quincke needle at L3-4 interspace, and 0.5% hyperbaric bupivacaine 2.5 ml with 0.15 mg morphine was injected. Block level was confirmed as T8 by a pinprick method. Blood loss during operation was 858 g, and complications were not seen during operation. In the case of delivery with uncontrolled aplastic anemia, elective cesarean section is thought to be safe. If platelet count is over 5.0 x 10(4) x microl(-1) after platelet transfusion, spinal anesthesia should be used.